Avoidable deaths and harm to patients

Stephen Ramsden, chief executive of Luton and Dunstable Hospital foundation trust and director of the National Patient Safety Campaign, writes about patient safety in the Health Service Journal.

Why have the public not asked why patients are harmed or die in hospitals around the country in situations which could be avoided?

The chorus of disapproval regarding hospital superbugs shows the public are aware of this issue. Reports in newspapers and on television about "dirty hospitals" has made the government realise they have to address the problem.

Could this be because the issue is "easier to understand? Or has it just simplified a complex problem?"

The matter of patient safety is a complicated one. My trust's non-executive directors did not comprehend why hand hygiene compliance scores stood at only 93% and not 100%.

The trust's executives shared disbelief at the fact they were as high as 93%. An audit revealed that the levels were actually around 45%.

Trying to communicate these issues to the press is very "difficult' as was proved to me when I spoke to a national newspaper.

In an attempt to portray how our hospital managed "acutely ill deteriorating patients" I said: "Patients are dying because they are not being observed."

The reporter asked what I meant by that. I said that there was a "failure to rescue sick patients who are getting sicker."

The reporter asked why the worsening of ill patients' conditions was not being identified.

I said: "Our nurses seem to have lost the art of taking reliable observations."

Reporter: "You mean the very sick patients are not getting their vital signs monitored?"

I said that "basic observations" were discontinued when electronic systems were put in place. Nurses had to be retrained in order to identify and monitor how patients were faring.

The reporter said that meant the problem was now solved. I answered that the observations were not always taken or "acted on".

The reporter said that this must mean patient deaths occur because of a lack of observation and I agreed.

The Patient Safety First campaign wants to address this problem, which is a "scandal" that has not yet been picked up by the media.